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PRIMARY RESEARCH

Suicidal ideation and suicide attempts

among asthma

Jae Ho Chung

1

, Sun‑ Hyun Kim

2*

and Yong Won Lee

1

Abstract

Background: The present study aimed to investigate the mental health status in patients with asthma and assess the effects of asthma on suicidal ideation and attempts using a representative sample from Korea.

Methods: Individual‑level data were obtained from 228,744 participants (6372 with asthma and 222,372 without asthma) of the 2013 Korean Community Health Survey. Demographic characteristics, socioeconomic status, physical health status, and mental health status were compared between patients with asthma and population without asthma. Multivariable logistic regression was performed to investigate the independent effects of the asthma on suicidal ideation and attempts. Results: A depressed mood for 2 or more continuous weeks was reported by 12.0% of subjects with asthma and 5.7% of controls (p < 0.001). Suicidal thoughts were reported by 21.4% of patients with asthma and 9.8% of controls (p < 0.001). Suicidal attempts were reported by 1.0% of the patients with asthma and 0.4% of controls (p < 0.001). Following adjustment for age, sex, income, education, job, marital status, smoking, alcohol, exercise, and presence of diabetes mellitus, hypertension, stroke, arthritis, and depression, the ORs for suicidal ideation with asthma were 1.53 (95% CI 1.42–1.65) and that for suicidal attempts was 1.32 (95% CI 1.01–1.73).

Conclusions: We found that asthma increased the risk for suicidal ideation and attempts, even controlling for the effects of socioeconomic status, physical health status, comorbid chronic medical diseases, and depressive mood. Our finding suggests that asthma per se may be an independent risk factor for suicidality.

Keywords: Suicidal ideation, Suicidal attempt, Asthma

© The Author(s) 2016. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Background

Many chronic diseases are complicated by emotional and psychological disorders and yet the emotional dimen-sions of such chronic diseases are frequently overlooked when medical treatment is considered [1]. Several stud-ies have found statistically significant correlates between asthma and suicide ideation and suicide attempts [2–6].

Suicide is the fourth leading cause of death in Korea [7]. Suicide rate was 33.3 per 100,000 persons in Korea in 2011, which ranked first among the Organization for Eco-nomic Co-operation and Development (OECD) coun-tries (https://data.oecd.org/healthstat/suicide-rates.htm).

Since asthma and suicide are important public health burdens, epidemiological study investigating the men-tal health status in asthma patients and its relationship with suicidal ideations and attempts would be required to assess the potential risk for suicide, and ultimately pre-vent suicidal completion in patients with asthma. How-ever, very few studies about the relationship between asthma and suicide have been done in Asia especially South Korea. There are a number of epidemiological dif-ferences among the studies that have evaluated suicidal behavior, and an investigation of the various comorbidi-ties and risk factors that lead to suicide in different ethnic groups is therefore necessary. As far as I know, this is the first study suicidal prevalence among asthma patients in Korea.

We aimed to compare the status of mental health including suicidal ideations and attempts between

Open Access

*Correspondence: sunhyun@yahoo.com

2 Department of Family Medicine, International St. Mary’s Hospital, Catholic Kwandong University College of Medicine, Simgokro 100 Gil 25 Seo‑gu, Incheon 22711, Republic of Korea

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patients with asthma and population without asthma using data from nationwide population-based health sur-vey (The 2013 Korean Community Health Sursur-vey).

Methods

Study participants

For this study, we obtained data from the 2013 Korean Community Health Survey (KCHS, https://chs.cdc. go.kr/chs/index.do), which was carried out by the Korea Centers for Disease Control and Prevention (KCDC). The KCHS is a nationwide cross-sectional health inter-view survey, annually conducted since 2008, to investi-gate the patterns of disease prevalence and morbidity as well as personal lifestyle and health-related behaviors in adults aged 19 years or older. The sample size for the KCHS is 900 subjects in each of 253 community units, including 16 metropolitan cities and provinces. The KCHS expects a total of 227,700 survey participants per year, but the actual number of respondents approximates 230,000. The KCHS has a two-stage sampling process. The first stage involves selection of a sample area (tong/ ban/ri) as a primary sample unit according to the num-ber of households in the area using a probability propor-tional to size sampling technique. In the second stage, sample households are selected in each sample area (tong/ban/ri) using systematic sampling methods. This process ensures that the sample units can be representa-tive of the entire population [8]. For the sample to be sta-tistically representative of the population, the data from the survey are weighted based on the sample design. The KCHS employs interviewers who were trained in com-puter-assisted personal interviewing techniques to col-lect information.

The institutional review board at the Korea Centers for Disease Control and Prevention approved the study protocol (2013-06EXP-01-3C), and all participants gave written informed consents.

In total, 228,781 individuals participated in the 2013 survey. This study was based on 228,744 participants, excluding 37 with insufficient data to confirm a doc-tor’s diagnosis with asthma. The final analysis identified 6372 asthma individuals who had been diagnosed by a doctor.

Baseline physical health

Physical health can affect an individual’s mental health and future mortality risk [3]. Conditions comorbid that include hypertension, diabetes, stroke, and arthritis were investigated in this study. The number of comorbid conditions was also evaluated which were based on the answer “yes” to the question “Were you diagnosed with diseases by a physician?” to avoid bias generated by sub-jective assessment.

Socioeconomic status

Indicators of socioeconomic status are associated with suicidal thoughts [9], and the present study therefore evaluated education, occupation, and household income. Self-reported smoking, alcohol intake, and physical activ-ity were estimated from questionnaire responses, and household income was categorized according to quartiles of total income for each member in the household. Mari-tal status was categorized as married, single, or divorced/ separated/widowed.

Suicide-related thoughts and behaviors are associated with health behaviors such as cigarette smoking [10], alcohol consumption [11], and exercise [12]. Thus, the present study assessed health behaviors such as smok-ing, drinksmok-ing, and regular exercise using self-reported questionnaires. People who had smoked 100 cigarettes (5 packs) or more in their lifetime and currently smoked were classified as a ‘smoker,’ while everyone else belonged to the ‘non-smoker’ group. Risky drinking was defined as drinking more than five alcoholic beverages on one occa-sion, and individuals who had drunk more than 12 drinks on one occasion during the previous year were classified as risky drinkers [13]. Regular exercise was defined as routine walking at least five times per week for at least 30 min at a time or engaging during the survey period in regular moderate (at least five times per week for at least 30 min at a time) or strenuous (at least three times per week for at least 20  min at a time) exercise as defined by the American College of Sports Medicine Guidelines [14]. Self-rated health status was analyzed using a 5-point scale, with responses of ‘very good’, ‘good’, ‘normal’, ‘poor’, and ‘very poor’.

Mental health measures

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they had experienced a depressive mood for 2 or more continuous weeks during the previous year. Suicidal ideation was assessed by participants’ positive answer to the question “In the last 12 months, did you think about committing suicide?” A “yes”’ or “no” response was also used to determine whether the subjects had suicidal idea-tions; if the subject answered “yes,” they were then asked about their suicide attempts, if any. This indicator is a well-documented predictor of suicide attempts that has been previously used in other surveys of adults [16].

Ethical issues

The institutional review board at the Korea Centers for Disease Control and Prevention approved the study pro-tocol (2013-06EXP-01-3C), and all participants gave written informed consents.

Data analysis

Descriptive statistical methods were used to describe the basic characteristics of the study population; the num-bers and percentages are reported for each variable. Stu-dent’s t test and Chi-square test were used to compare variables between patients with asthma and population without asthma. Multivariable logistic regression analy-sis was conducted to calculate the adjusted odds ratios (ORs) for suicidal behavior among the asthma patients; we included age, sex, income, education, job, marital status, smoking, alcohol, exercise, presence of diabetes mellitus, hypertension, stroke, arthritis, and depression. Results were expressed with a 95% confidence interval (CI). All data were analyzed using the Statistical Package for Social Sciences (Version 20.0; IBM, Armonk, New York).

Results

The baseline characteristics of the study population (n = 228,744) are presented in Table 1. As compared to population without asthma (n = 224,175), patients with asthma (n =  6372) were older and had higher propor-tions of female, smoker, being alone (divorced/separated/ widowed), hypertension, stroke, arthritis, and had lower level of education, lower level of income, lower propor-tions of alcohol drinking, regular exercise, and less hav-ing a job (all p < 0.001).

Differences in mental health status between asthma patients and population without asthma were presented in Table 2. Asthma patients reported more moderate to severe stress (33.4%) and depressive mood (12.0%) as compared to population without asthma (25.4%, p < 0.001; 5.7%, p < 0.001). The rate of asthma patients who had suicidal ideations (21.4%) was higher than twice the rate in population without asthma (9.8%, p < 0.001). The rate of asthma patients who had suicidal attempts

(1.0%) was higher than three times the rate in population without asthma (0.4%, p < 0.001).

The ORs of suicidal ideation and attempts among the asthma patients in comparison to population without asthma was presented in Table 3. A multivariate analy-sis adjusting for age and sex (model 1) revealed that the ORs for suicidal ideations and attempts were 2.01 (95% CI 1.89–2.14) and 2.42 (95% CI 1.87–3.12), respectively. When additional adjustments were performed for socio-economic factors (i.e., family income, education, job, and marital status; model 2), the ORs for suicidal idea-tions and attempts were 1.84 (95% CI 1.72–1.96) and 2.12 (95% CI 1.63–2.75), respectively. After additional adjust-ments for factors related to physical health (i.e., smok-ing, alcohol, exercise, diabetes, hypertension, stroke, and arthritis; model 3), the ORs for suicidal ideations and attempts were 1.71 (95% CI 1.59–1.82) and 1.79 (95% CI 1.37–2.33), respectively. In a final model adjusted for all of factors including depressive mood (model 4), the ORs for suicidal ideations and attempts were 1.53 (95% CI 1.42–1.65) and 1.32 (95% CI 1.01–1.73), respectively.

Discussion

Our study showed that asthma patients had more severe stress, depressive mood, suicidal ideations, and attempts than population without asthma. In addition, asthma was associated with an increase in the risk for suicidal ideations and attempts, even after adjusting for factors that are known to increase suicidality such as socioeco-nomic status, chronic medical diseases, and depressive symptoms.

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adjusting for confounding factors such as mood disorder, poverty, smoking, and demographics. Our study showed suicidal ideation (OR 1.53; 95% CI 1.42–1.65) and sui-cidal attempts (OR 1.32; 95% CI 1.01–1.73).

This present study cannot explain the mechanisms of the association between asthma and suicidal ideation and suicidal attempts. An association between asthma morbidity, risk-taking behavior, and depression has been

Table 1 Clinical characteristics of study populations

No asthma (n = 222,372) Asthma (n = 6372) P value

Age (years) 51.8 ± 17.0 61.1 ± 17.8 <0.001 Sex (Male %) 100,089 (45.0) 2605 (40.9) <0.001

Smoking status <0.001

Smoker 81,882 (36.8) 2562 (40.2) Non‑smoker 140,490 (63.2) 3810 (59.8)

Alcohol drinking 59,896 (26.9) 1050 (16.5) <0.001 Regular exercise 114,714 (51.6) 3047 (47.8) <0.001

Marital status <0.001

Married 152,061 (68.4) 3844 (60.4) Single 33,101 (14.9) 683 (10.7) Divorced/separated/widowed 37,072 (16.7) 1839 (28.9)

Job 140,886 (63.4) 2914 (45.8) <0.001

Family income <0.001

Low 52,214 (24.3) 2705 (43.9)

Moderate‑low 43,285 (20.2) 1258 (20.6) Moderate‑high 70,830 (33.0) 1303 (21.1) High 48,400 (22.5) 887 (14.4)

Education <0.001

≤Elementary 57,240 (25.8) 3067 (48.2) Middle school 25,346 (11.4) 811 (12.8) High school 64,235 (29.0) 1197 (18.8)

≥College 75,165 (33.8) 1282 (20.2)

DM 11,623 (5.2) 306 (4.8) 0.075

Hypertension 53,068 (23.9) 2523 (39.6) <0.001

Stroke 4305 (1.9) 252 (4.0) <0.001

Arthritis 29,761 (13.4) 1884 (29.6) <0.001

Table 2 Mental health of asthma patients

No asthma (n = 222,372) Asthma (n = 6372) P value

Stress <0.001

Moderate to severe 56,507 (25.4) 2120 (33.4) None to mild 165,685 (74.6) 4236 (66.6)

Perceived health status <0.001

Very good 13,177 (5.9) 142 (2.2)

Good 73,803 (33.2) 1016 (16.0)

Moderate 89,422 (40.2) 2194 (34.5)

Bad 35,534 (16.0) 2010 (31.6)

Very bad 10,381 (4.7) 1006 (15.8)

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presented in previous research, although the reasons and direction of this association are not clear [17]. Asthma may be associated with mood change, anxiety, and some difficulties in daily living which may themselves feel hopelessness and consequently increased suicide risk [18]. Another possible mechanism for this association concerns effects of hypoxia [19], and it has been sug-gested that an association between high altitude and sui-cide may be accounted for by metabolic stress associated with hypoxia in individuals who have mood disorders. Recent research reports that suicide rates are elevated in those living at higher altitudes [8, 20], smokers [21, 22] and asthma [6, 23]. A possible mechanism that was pro-posed is metabolic stress associated with hypoxia. Young SN propose that low brain serotonin synthesis due to hypoxia could be a factor in the high suicide rates seen in people living at altitude, smokers and patients with chronic obstructive pulmonary disease (COPD) and asthma [24]. As pulmonary function decreases, and as the disease progresses, the risk of alveolar hypoxia and consequent hypoxemia increases [25]. Another poten-tial cause of depression in asthma sufferers is the use of particular medications, including corticosteroid or mon-telukast sodium, which, while reducing the symptoms of asthma, have also been linked to mood disturbances sim-ilar to the symptoms of major depression [26, 27].

The strength of our study is that data were obtained from a nationwide population-based survey with a large sample size (n = 228,744) and the sampling methods

rep-resentative of the general population. Moreover, the sur-vey provided information about a number of factors that might be related to suicidality, such as socioeconomic variables and physical health as well as mental health measures, which allows us to assess the independent effects of asthma on suicidality using multiple statistical adjustments.

Our study has some limitations that should be addressed. First, because this is a cross-sectional study,

temporal relationship and causality between asthma and suicidality could not be determined. Second, all data in this survey are based on self-reported questionnaires; therefore, the recall bias leading to the possibility of over- or under-reporting cannot be excluded. In addition, our study sample might be biased toward mild asthma patients who could complete the questionnaires. Third, we could not obtain detailed information about severity of asthma.

Conclusion

In summary, we observed that asthma patients had more depressive mood and suicidal ideation and attempts than population without asthma using a large population-based survey. We also found that asthma increased the risk for suicidal ideation and attempts, independent of other factors that are known to be asso-ciated with suicidality, suggesting that asthma per se may be an independent risk factor for suicidality. Given that a previous suicidal attempt is among the strong-est risk factors for future attempt [28], our findings may warrant the need for physicians to screen for suicidality and provide psychosocial support as well as interven-tions for preventing suicide in management of asthma patients. Hence any treatment modality for asthma, to minimize the possibility of suicide in patients with asthma, must incorporate. More research is required in the mental health field and asthma, but the indicators are clear that there is a significant association between asthma and suicide. Patients with asthma must be assessed not only for physical health but also for psy-chological morbidity.

Authors’ contributions

JHC served as a principal investigator and had full access to all of the data in the study. YWL participated in its coordination and helped to draft the manu‑ script. SHK is responsible for the integrity and accuracy of the data. All authors read and approved the final manuscript.

Author details

1 Department of Internal Medicine, International St. Mary’s Hospital, Catholic Kwandong University College of Medicine, Incheon, Republic of Korea. 2 Department of Family Medicine, International St. Mary’s Hospital, Catholic Kwandong University College of Medicine, Simgokro 100 Gil 25 Seo‑gu, Incheon 22711, Republic of Korea.

Acknowledgements

None.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

The data will not be made available in order to protect the participants identity.

Ethics approval and consent to participate

The institutional review board at the Korea Centers for Disease Control and Prevention approved the study protocol (2013‑06EXP‑01‑3C), and all partici‑ pants gave written informed consents.

Table 3 Odds ratio (95% CI) suicidal ideation and suicidal attempts for asthma

Adjusted for age, sex variable in model 1. Adjusted for age, sex, family income, education, job, marital status variables in model 2. Adjusted for age, sex, family income, education, job, marital status, smoking, alcohol, exercise, physician diagnosed diseases (diabetes, hypertension, arthritis, stroke) variables in model 3. Adjusted for age, sex, income, education, job, marital status, smoking, alcohol, exercise, physician diagnosed diseases, depression in model 4

Suicidal ideation

OR (95% CI) Suicidal attemptsOR (95% CI)

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Funding

This work was supported by research fund of Catholic Kwandong University International St. Mary’s Hospital (CKURF‑201601560001). These funds were used for collection, analysis, and interpretation of data.

Received: 25 October 2016 Accepted: 19 November 2016

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Figure

Table 2 Mental health of asthma patients
Table 3 Odds ratio (95% CI) suicidal ideation and suicidal attempts for asthma

References

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